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A maxed-out liver: a case of acute-on-chronic liver failure.


A 51-year-old man from Puerto Rico with Child-Turcotte-Pugh Class C decompensated cirrhosis due to genotype 1a chronic hepatitis C was referred for worsening jaundice and diuretic-resistant ascites. He began experiencing symptoms of hepatic decompensation 5 months prior to referral with new-onset ascites and spontaneous bacterial peritonitis, evolving into diuretic-resistant ascites, increasing jaundice, and a MELD increase from 12 to 29. During his hospitalization, his MELD score increased to >40 from a rapidly increasing international normalized ratio (INR) and evolving type 1 hepatorenal syndrome. Clinically, the patient appeared quite well despite such a high MELD score. After an extensive pretransplant evaluation and exclusion of infection, he underwent successful orthotopic liver transplantation. After histologic examination of the explanted liver, he subsequently admitted to 5 months of daily use of a detoxifying supplement known as MaxOne (®), containing D-ribose- L-cysteine, consistent with a drug-induced acute-on-chronic liver failure. The use of complementary and alternative medicines and its potential for causing drug-induced liver injury and acute-on chronic liver failure requires a high index of suspicion and increased awareness among health care providers.


  • Publisher Full Text
  • Authors+Show Affiliations


    Division of Liver Diseases, The Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029, USA.

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    Seminars in liver disease 31:4 2011 Nov pg 420-6


    Diagnosis, Differential
    Drug-Induced Liver Injury
    End Stage Liver Disease
    Hepatitis C, Chronic
    Hepatorenal Syndrome
    Liver Cirrhosis
    Liver Failure, Acute
    Liver Transplantation
    Middle Aged

    Pub Type(s)

    Case Reports
    Journal Article



    PubMed ID